Cornea editor’s corner of the world
When to avoid the herpes zoster vaccine

Shingles or the recurrence of varicella zoster virus (VZV) can be a very painful experience for a patient. Particularly in the elderly population, there may be long term sequelae, including post-herpetic neuralgia, which can significantly decrease the quality of life for the patient.
The herpes zoster vaccine is recommended for those 50 years of age or older regardless of whether or not the patient had a prior episode of VZV. Patients who are immunosuppressed, pregnant, or have a history of allergy to any component of the vaccine should avoid the vaccine.
Ophthalmologists certainly see patients with acute herpes zoster ophthalmicus (HZO) ora related chronic sequelae, as well as those with a history of prior HZO. There have been several reports of HZO recurrence after patients receive the vaccine, thus some cornea specialists argue that recent prior HZO may be considered a relative contraindication.
In this month’s “Cornea editor’s corner of the world,” Sonal Tuli, MD, and Todd Margolis, MD, PhD, discuss their clinical experience and recommendations about which ophthalmic patients may or may not benefit from the herpes zoster vaccine.

Clara C. Chan, MD,
FRCSC, FACS,
Cornea editor

Evidence continues to build that some patients may want to avoid the vaccine

Evidence continues to emerge that patients vaccinated for herpes zoster (HZ) can develop a recurrence of keratouveitis because of the vaccine-induced increase in cell-mediated immunity (CMI). Avoiding vaccination in some individuals with previous zoster infections may be prudent.
A shingles, or HZ, vaccine (Zostavax, Merck, Whitehouse Station, New Jersey) was first approved in 2006 by the U.S. Food and Drug Administration. That approval has been expanded to include individuals age 50 years and older. However, the safety of the vaccine in patients with a history of zoster has not been comprehensively studied.
Individual cases continue to emerge in which patients with a history of HZ keratitis with persistent viral antigens in their corneas develop recurrence of keratouveitis because of the vaccine-induced increase in CMI.
Sonal Tuli, MD, professor and chair, Department of Ophthalmology, University of Florida, Gainesville, Florida, co-authored a case report on a 63-year-old man with a history of HZ keratouveitis and neurotrophic keratopathy, who was quiescent for 3.5 years off medication but presented with keratouveitis 2 weeks after Zostavax administration.1
That case report was published in 2013 and Dr. Tuli said he has had two additional such cases since then.
“All were stable before the vaccination and had recurrence of their ocular inflammation about 2 to 3 weeks after getting the shingles vaccine,” Dr. Tuli said.
Todd Margolis, MD, PhD, Alan A. and Edith L. Wolff Distinguished Professor and chairman, Department of Ophthalmology, Washington University School of Medicine, St. Louis, has similarly cared for patients with recurrent keratitis and iritis soon after vaccination with Zostavax.
“It appears to be a reactivation of the disease,” Dr. Margolis said. “I don’t think it is a reactivation of the virus. You just boosted the immune response with the vaccination and these patients have immunological driven disease in the eye.”
The findings have led some ophthalmologists to urge caution before providing the vaccine to patients with a history of HZ ophthalmicus.

Recommendations

The vaccine is approved for individuals 50 years and older and recommended by the Centers for Disease Control and Prevention for those 60 years and older.
“I think everyone 50 years and older should be getting vaccinated—but that’s my opinion,” Dr. Margolis said.
Contraindications include allergies to any ingredients of the vaccine and patients who are immune compromised to an unknown degree.
“It is a live, attenuated virus so you don’t give this to someone who is severely immune compromised. There are different recommendations based on the degree to which someone’s immune system is compromised,” Dr. Margolis said.
The vaccine is recommended even for people who have previously had zoster, Dr. Tuli said. There is no official recommendation as to how long after having zoster they should wait before they get the vaccine.

Approaches vary

Dr. Tuli tells patients with a history of non-ocular involving herpes zoster that they don’t need it because their immune system and cell-mediated immunity for zoster has been boosted for about 10 years “but that there is no harm in getting it.”
The Shingles Prevention Study (SPS) showed that the CMI that occurs due to an episode of shingles is equal to the CMI that develops as a result of vaccination.2
“Therefore, getting shingles is like giving yourself a shingles vaccination,” Dr. Tuli said.
Dr. Margolis agreed that the chance of such patients developing another true episode within 5 years is low so there is no rush to get the vaccine.
“Patients should get it but the question is when; there’s no real data for that,” Dr. Margolis said.
However, in cases of active iritis or keratitis, Dr. Margolis tells patient not to get the vaccine.
“I warn them that getting it has a small but real risk of causing their iritis or keratitis to recur or get worse because of the immune response to antigens in the eye,” said Dr. Margolis, who has published reports on such iritis and keratitis cases.
Similarly, Dr. Tuli recommends against the vaccination for at least 10 years after they have had the zoster episode if their corneas were involved at all (not just the eyelids).
“That is because their CMI from the zoster episode will protect them from getting zoster again,” Dr. Tuli said. “However, the boost in their CMI and antigens from the vaccine may reactivate the inflammation that attacked their cornea previously and cause worsening of the ocular problems.”

Antivirals

Dr. Tuli noted that there is no role for an oral antiviral or topical antiviral prophylactically prior to the vaccine in patients with a history of ocular involving disease.
“Giving antivirals with the vaccination would make the vaccine ineffective since it is a live attenuated vaccine,” Dr. Tuli said. “We think the recurrence is due to the patient’s immune system attacking the residual viral antigen in the eye (from the previous episode of zoster). Antivirals would not help prevent that because it is not live virus that attacks the cornea with vaccination.”
U.S. patients may soon have another vaccine option, which is undergoing drug trials. That vaccine from GlaxoSmithKline is not an attenuated virus and in trials has shown 97% efficacy at blocking shingles, compared to about a 50% efficacy with the current vaccine, Dr. Margolis said. Importantly, patients vaccinated with the previously approved option will be able to receive the coming vaccine if they are at high risk for shingles.